What ends questionably – or unexpectedly – ends up here amid small talk and dark suits, plastic cups of tepid water and the faint smell of cigarettes. The Coroners Court of Victoria is brighter than expected. Sun pours through circular skylights, mixing with the glow of light bulbs in the ceiling and the walls. In courtroom one, where Coroner Caitlin English is leading an inquest into the suicide of a 27-year-old man, one wall is mostly window.

The issue before English today is not the cause of death per se, but its circumstances and whether it could have been prevented. The man had attended a public hospital as a mental-health patient just before he died.

English sits alone at the bench under the Court’s insignia, which bears words that are wishes we hold for ourselves and our children: Peace and Prosperity. Though the environment is pleasant – all soft green fabrics and honey-coloured wood – the work today seems excruciating. It is the work of all courtrooms: a striving to reconcile gross disequilibrium in recollections and emotions and concerns; a meticulous mining of the particulate elements of human behaviour only to surface with a rational explanation that pins its hopes on approximation. However, today court staff are also dealing with the loss of one of their colleagues, a female senior lawyer, to suicide.

A line of black blazers at the bar table faces the witness box. The father is giving a statement. The room falls silent when he is asked whether he has seen his child’s autopsy results.

Coroners investigate particular deaths to identify their causes or circumstances. In doing so, they contribute to the reduction of preventable deaths and the promotion of public safety. So, while it doesn’t feel immediately apparent on this morning as the parents exit the courtroom, unable to re-watch the CCTV footage of their son’s final moments, the coronial function, too, is brighter – more positive – than many would expect.

“So many families come to court and what they are saying is, essentially, ‘I just don’t want this to happen to another family’,” English says when we sit down a couple of weeks later. To assist in this function, the Court established the Coroners Prevention Unit, a specialist service that collects and uses data to identify opportunities to improve public health and safety.

This work is what attracted English, who was appointed as a magistrate in 2000, to the Court four years ago.

“I’ve always had an interest in public policy, and the coroners’ jurisdiction represents that real intersection of law and policy. You might be dealing with an individual case, but because the recommendations power is about reducing the number of preventable deaths it means you can have a far greater systemic effect.”

There are approximately 6000 reportable deaths a year in Victoria. These include deaths in state custody or care; deaths that appear “unexpected, unnatural or violent”; deaths that occur during or following a medical procedure; and deaths where the identity of the person is unknown. They come from hospitals, jails, mental-health institutions, aged-care facilities, private homes and public spaces, and they end up at the Victorian Institute of Forensic Medicine, co-located with the Coroners Court, as cases for consideration. The cases are distributed among 11 coroners who, after considering the advice of a forensic pathologist, make orders about whether an autopsy is necessary.

“On a Monday you might get over 50; today I think there was mid 20s,” English says, fresh from performing this particular duty. “They become the cases that we investigate.”

Only 1.3 per cent of investigations result in an inquest. While these are mandatory in certain situations, such as deaths in custody, inquests are usually held when an issue of public importance requires additional information. Unlike other court cases, the process is inquisitorial, not adversarial.

“It’s not determining whether someone is negligent,” English explains. “And it’s not a criminal case determining whether someone is guilty. The coronial process is quite different – it’s fact finding.”

It is striking: a legal environment of high emotion where context is privileged over culpability and used at the service of our collective future.

The utility of the law lies in its clean lines. The rules that govern its internal logic enable it to transfigure the chaos of human life into clear explanation. And yet, sometimes, to pinpoint an answer is simply to restate the question.

Suicide is the leading cause of death for Australians aged between 15 and 44. In 2017, 3128 Australians took their own life, an increase of 262 from the previous year. In the same year, 40 per cent of reportable deaths in Victoria were due to natural causes, a further third were accidental, and 11 per cent were suicides. The figures from the Victorian Suicide Register, created and managed by the Coroners Court, indicate that over the past five years the number has gradually risen.

“It’s one of the biggest shocks of actually becoming a coroner, learning about suicide rates,” English says. “I think that generally people aren’t aware of how the suicide rate is higher than the road toll, higher than the homicide rate. I think an incredibly valuable tool that we have is the Victorian Suicide Register, that’s been developed over a period of years to identify possible factors that are causes in suicide.”

She says that, since joining the Court in 2014, she has seen an increasing number of suicide deaths involving methamphetamine.

Is it always clear whether a death was intentional, and what led the person there?

“That’s an issue coroners grapple with every single day because we’re doing these cases every single day,” English says. “There’s an old common law presumption against suicide … It’s something that coroners are thinking about all the time in terms of determining whether there’s sufficient evidence to support a finding of intent.”

Does a tension often arise between accuracy in the public interest and what the family may want to hear?

“I think there’s a strong tension,” English replies, explaining the importance of being sensitive to the family’s concerns about how the cause of death is categorised and whether intent is found. If other explanations are consistent with a lack of intent, the coroner will investigate them and take them into account. “Particularly young people. I think there’s a strong argument as to whether there’s an appreciation or understanding of the consequences and finality of some actions. It’s not clear cut.”

In 2017, suicide remained the leading cause of death for both Indigenous and non-Indigenous children and young people, and it accounted for 40 per cent of all Indigenous child deaths. The suicide rate among Indigenous Australians is more than double the national rate. The LGBT and gender diverse community is also disproportionately affected: beyondblue states that 81 per cent of gender diverse young people who had experienced abuse and/or discrimination due to not identifying with a specific gender had thought about suicide; 37 per cent had attempted it. This conforms with the constellation of risk factors identified by the research, which include social and emotional isolation, trauma and ongoing exposure to bullying in addition to physical and mental illness and substance abuse. Research also indicates the power of protective factors: social connections and supports, access to local health services, a sense of purpose and control, and, perhaps, access to stories of non-suicide alternatives to life crises.

As encyclopaedias of little-discussed but universal human experience, coroners learn, in their daily work, details that will return in the night. English thinks for a long moment when I ask about self-care. She mentions a painting course. She loves reading. But mostly she answers by speaking highly of the judicial counselling for coroners, a world first, instituted in 2009 in response to the Court’s investigation into the Victorian bushfires. Various counselling services are available to all staff and are being increased.

For judicial officers, it is a fact of the job that “sitting in court is quite isolating, or lonely, in the sense that you’re not actually part of a team”. Add to that the typical response when asked what you do for a living. “It’s a conversation stopper. It’s really quite hard to go forward once people find out you’re a coroner. Maybe it’s that reluctance to talk about death or not quite knowing enough to be able to ask a question. It’s not really schoolyard talk with the mums.” So it is a good thing that coroners “are very collegiate”.

“The people are very self-selecting when you get to the Coroners Court,” says English.

“I suppose they’re people who are very conscious of maintaining that important work–life balance and who get on with people. I think more so than any other work environment, at the Coroners Court, where you’re looking at the edge of the abyss every day, the small interactions of collegiality are extremely important.”

Given the importance of collegiality, it appears that the Court finds itself at a vulnerable moment; the state coroner, Judge Sara Hinchey, has stepped aside from her role as head of the Court while the Judicial Commission hears a complaint about her. Meanwhile, the coroners continue with their work.

English says that the main quality a coroner needs has to be love of the work.

“It’s a privilege and an honour. You’re speaking for the dead. I think it’s the motto of the Ottowa coroners court – speaking for the dead to protect the living.”

Sarah Krasnostein is a writer, lecturer and a legal researcher with a doctorate in criminal law. She is the author of The Trauma Cleaner, which won the 2018 Victorian Prize for Literature, the Victorian Premier’s Literary Award for Non-Fiction and the Australian Book Industry Award for Non-Fiction.

What ends questionably – or unexpectedly – ends up here amid small talk and dark suits, plastic cups of tepid water and the faint smell of cigarettes. The Coroners Court of Victoria is brighter than expected. Sun pours through circular skylights, mixing with the glow of light bulbs in the ceiling and the walls. In courtroom one, where Coroner Caitlin English is leading an inquest into the suicide of a 27-year-old man, one wall is mostly window.

The issue before English today is not the cause of death per se, but its circumstances and whether it could have been prevented. The man had attended a public hospital as a mental-health patient just before he died.

English sits alone at the bench under the Court’s insignia, which bears words that are wishes we hold for ourselves and our children: Peace and Prosperity. Though the environment is pleasant – all soft green...